Absorbable Sutures

Absorbable sutures for facial lacerationsWound care is a common issue in the ED. Certainly, not all wounds are created equal. We have discussed eyelid lacerations and tongue lacerations. We have also discussed my favorite wound closure technique: tissue adhesives. While tissue adhesives are pretty awesome, they aren’t appropriate for all scenarios.  Sometimes you need sutures.  I was taught that you use absorbable sutures to close deep layers and non-absorbable to close the surface. Pretty simple and made sense; however, removal of sutures is not always simple and sedating a child just to remove strings doesn’t seem to make much sense. Recently, there has been an evolving trend that challenges the myth that all skin closure is done with non-absorbable suture. Let us take a minute to digest a Morsel of information about Absorbable Sutures for primary wound closure.

 

Sutures: Basics

  • The primary purpose of sutures is to hold apposing tissues together to facilitate healing, while minimizing scar and complications.
  • There is no single suture material that is suitable for all wounds. [Dennis, 2016]
  • Choice of suture depends upon a number of factors:
    • Wound tension (strength of suture)
    • Depth and number of tissue layers involved
    • Presence of edema
    • Expected time of wound healing
    • Inflammatory reactions from suture
    • Ease of use 
    • Security of knot

 

Absorbable Sutures: Examples

  • Absorbable suture = suture that undergoes degradation and absorption in tissue.
  • Polyglactic 910 (ex, Vicryl) [Hochberg, 2009]
    • Retains 65% of its tensile strength at 2 weeks; 40% at 3 weeks.
    • Complete absorption occurs between 60 and 90 days.
    • Very useful for completely buried sutures apposing deep tissues.
  • Rapid Absorbing Coated Polyglactic 910 (ex, Vicryl Rapide) [Hochberg, 2009]
    • Partially hydrolyzed and processed to speed up absorption.
    • 50% tensile strength at 5 days; 0% at 2 weeks.
    • Sutures can be absorbed in 10-14 days.
  • Poliglecaprone (ex, Monocryl) [Hochberg, 2009]
    • Retains ~40% of its tensile strength at 2 weeks.
    • Absorption is in ~90-120 days.
    • Has significant initial tensile strength, so closure can be done with a suture 1-2 sizes smaller than normal.
    • Good for subcuticular closure.
  • Gut [Hochberg, 2009]
    • Made from twisted strands of purified collagen prepared from sheep or cattle small intestine.
    • Comes in three varieties: Chromic, Plain, and Fast-Absorbing
      • Chromic gut is tanned to decrease absorption rate. Absorption in 21 days.
      • Plain gut is untreated. Absorption in 10-14 days.
      • Fast-absorbing gut is head-treated to increase absorption rate. Absorption in 7 days.
      • Fast-absorbing gut has less tensile strength than plain gut.
      • Fast-absorbing gut is used primarily for epidermal suturing.

 

Absorbable Sutures: For Lacerations

  • Controversy exists over using absorbable sutures for epidermal wound closure.
    • Some avoid absorbable sutures due to “concerns” for increased scar formation, increased wound dehiscence, and increased wound infection.
    • Others advocate for absorbable suture use, particularly in children, as it may avoid the challenges of having to remove sutures.
  • There are several studies that demonstrate the utility and safety of using absorbable sutures, specifically in children. [Tejani, 2014; Luck, 2013; Luck, 2008; Karounis, 2004]
    • Vicryl Rapide has been shown to be useful in closure of simple lacerations on the trunk and extremities. [Tejani, 2014]
    • Fast-absorbing gut showed no significant clinical difference to non-absorbable suture for facial lacerations at 3 months. [Luck, 2008]
    • Fast-absorbing gut did not have higher rates of wound infection or complications compared to non-absorbable. [Luck, 2008]
    • Plain gut has also been found to be an acceptable alternative to non-absorbable suture for pediatric wound repair. [Karounis, 2004]
  • So it would appear that the concerns about increased scar formation, wound dehiscence, and infection should not be as concerning as we may have been taught.

 

Absorbable Sutures: Proposed Strategy

  • Always take care to anticipate the patient’s pain/anxiety to help avoid causing post-wound repair PTSD!
    • Consider nitrous oxide or intranasal medications even if you don’t think you will need full procedural sedation.
    • This may help when the patient returns for wound reassessment, etc.
  • Default to using absorbable sutures in children when sutures are required.
    • Consider using Vicryl Rapide for extremities and trunk.
    • Consider using Fast-Absorbing Gut for facial lacerations.
  • If there is too much tension at the epidermal wound edges, consider deep layer closure.
    • This may then allow for absorbable suture closure at the surface.
    • Obviously, some wounds will still require non-absorbable sutures (ex, over joints, high tension).
  • Still recommend removal of absorbable sutures at the appropriate time interval.
    • This is particularly useful in areas that heal more rapidly than the suture dissolves (i.e., the face).
    • Removing the suture may help to continue to minimize scar formation risk.
  • If the child will not easily and calmly tolerate suture removal, the presence of the absorbable sutures allows for the suture removal procedure to be aborted.
    • Simply trim down the sutures as much as allowed.
    • Can recommend some gentle massage to help speed up the absorption process.

 

References

Dennis C1, Sethu S2, Nayak S1,3, Mohan L4, Morsi YY5, Manivasagam G1. Suture materials – Current and emerging trends. J Biomed Mater Res A. 2016 Jun;104(6):1544-59. PMID: 26860644. [PubMed] [Read by QxMD]

Tejani C1, Sivitz AB, Rosen MD, Nakanishi AK, Flood RG, Clott MA, Saccone PG, Luck RP. A comparison of cosmetic outcomes of lacerations on the extremities and trunk using absorbable versus nonabsorbable sutures. Acad Emerg Med. 2014 Jun;21(6):637-43. PMID: 25039547. [PubMed] [Read by QxMD]

Luck R1, Tredway T, Gerard J, Eyal D, Krug L, Flood R. Comparison of cosmetic outcomes of absorbable versus nonabsorbable sutures in pediatric facial lacerations. Pediatr Emerg Care. 2013 Jun;29(6):691-5. PMID: 23714755. [PubMed] [Read by QxMD]

Hochberg J1, Meyer KM, Marion MD. Suture choice and other methods of skin closure. Surg Clin North Am. 2009 Jun;89(3):627-41. PMID: 19465201. [PubMed] [Read by QxMD]

Luck RP1, Flood R, Eyal D, Saludades J, Hayes C, Gaughan J. Cosmetic outcomes of absorbable versus nonabsorbable sutures in pediatric facial lacerations. Pediatr Emerg Care. 2008 Mar;24(3):137-42. PMID: 18347489. [PubMed] [Read by QxMD]

Karounis H1, Gouin S, Eisman H, Chalut D, Pelletier H, Williams B. A randomized, controlled trial comparing long-term cosmetic outcomes of traumatic pediatric lacerations repaired with absorbable plain gut versus nonabsorbable nylon sutures. Acad Emerg Med. 2004 Jul;11(7):730-5. PMID: 15231459. [PubMed] [Read by QxMD]

Sean Fox

I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renown educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.

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4 Responses

  1. Helena Wang-Flores says:

    Hi Sean. We use the fast absorbing gut usually in the face. We have 6.0 but be warned it is VERY delicate and often hard for trainees to use because it often will break. Our ENT docs actually prefer the 5.0 over the 6.0.

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